2a(9)(a)
APPLICATION FORM FOR RIDERS AND CARRIAGE DRIVERS
2a(9)(a)
PLEASE USE BLOCK CAPITALS AND RETURN TO ADDRESS BELOW
GROUP NAME
CHARITY NO
NAME
ADDRESS
TEL NO
Thornton Rose RDA
SC028617
Kim Taylor Client Coordinator
Thornton Rose RDA
Thornton Farm
Rosewell, Midlothian EH24 9EF
Confidential information for use by relevant RDA personnel only
Applicants should note that this information may be stored on a computer system; the form will be
held securely in Group records
A REVIEW OF THE CONTENTS OF THIS FORM WILL NORMALLY BE REQUESTED AFTER 3-5 YEARS.
RDA RESERVES THE RIGHT TO REFUSE ANY RIDER OR CARRIAGE DRIVER ON GROUNDS OF HEALTH
AND SAFETY AT ANY TIME
THIS FORM MAY NEED TO BE REVIEWED IN THE EVENT OF THE RIDER/CARRIAGE DRIVER
APPLYING FOR AN RDA HOLIDAY
Next Recommended date for Review:_____________________
If you are under 18 years or someone else normally completes your paperwork for you, it should be completed
and signed on your behalf by your parent or guardian.
1
APPLICANT’S DETAILS
Surname, First Name
Date of Birth
Address
Telephone Number
2
PERSONAL INFORMATION
Height
Weight
Speech
Eyesight
Do you have problems with speech ?
Do you have problems with eyesight ?
Do you wear glasses / contact lenses?
Yes
Yes
Yes
No
No
No
Hearing
Do you have difficulty with hearing ?
Do you wear a hearing aid ?
Do you have difficulty understanding simple instructions ?
Do you need help with walking ?
Do you use walking aids ?
Do you wear orthopaedic appliances ?
Do you use a wheelchair ?
Would weight-bearing be a problem ?
Do you have any previous experience with an RDA Group ?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
Instructions
Walking
Riding/Carriage
Driving
If YES, have you passed any proficiency tests ?
Please give any other information that you think would be useful
March 2005
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2a(9)(a)
3
MEDICAL INFORMATION
(THIS DOES NOT CONSTITUTE CONSENT)
This should be completed by a Medical Professional who is familiar with and understands your medical
problems
Details of Specific Disabilities
Note of special Problems (eg Allergies, Asthma, Autism, ADHD, Balance, Circulation, Diabetes, Epilepsy etc)
MEDICAL PROFESSIONAL COMPLETING SECTION 3 ABOVE
Name
Appointment
Address
Telephone Number
Signature
4
APPLICANT’S SCHOOL OR TRAINING CENTRE (if applicable)
Name
Address
Telephone Number
Person to contact
5
APPLICANT’S PARENT OR GUARDIAN
Name
Address
HomeTelephone
Number
Emergency contact
Number
6
DECLARATION (to be completed by you or, on your behalf, by your parent or guardian)
I wish to join the Group as a rider/carriage driver and agree that the details of my medical history, which will
assist the Group Instructor, may be disclosed by my medical professionals.
I confirm that I will advise you immediately if any of the information provided on this form changes in any way.
I recognise that this activity involves risk and that I, the rider/carriage driver, should take all reasonable
precautions and follow all advice properly given.
In the absence of any negligence on the part of the RDA or the Group, I accept that no liability will attach to
either of them.
Do you agree that photographs/videos taken during Group activities may be used for training/publicity?
Date
Signature
Rider/Carriage
Driver/Parent/Guardian
(Delete as appropriate)
Riding for the Disabled Association Incorporating Carriage Driving (RDA)
Registered Company Number 5010395 Registered Charity No 244108 (England & Wales) No SC039473 (Scotland)
Norfolk House, 1a Tournament Court, Edgehill Drive, Warwick CV34 6LG
March 2005
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